Research ArticleAcupuncture and Related Therapies for Obesity:A Network Meta-Analysis

Yanji Zhang ,1 Jia Li ,1,2,3 GuoyanMo,4 Jing Liu,1

Huisheng Yang,5 Xianglin Chen ,1 Hui Liu ,1 Teng Cai ,1 Xian Zhang ,1

Xiangmin Tian ,1 Zhongyu Zhou ,2,3 andWei Huang 2,3

1College of Acupuncture and Orthopedics, Hubei University ofChinese Medicine/Hubei Provincial Collaborative Innovation Center of Preventive Treatment byAcupuncture and Moxibustion, Wuhan, China

2Department of Acupuncture, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China3Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China4China Key Laboratory of TCM Resource and Prescription, Hubei University of Chinese Medicine,Ministry of Education, Wuhan, China

5Institute of Acupuncture and Moxibustion of China Academy of Chinese Medical Sciences, Beijing, China

Correspondence should be addressed to Zhongyu Zhou; 2209447940@qq.com andWei Huang; huangwei@hbhtcm.com

Received 21 August 2018; Accepted 9 September 2018; Published 30 September 2018

Academic Editor: Mariangela Rondanelli

Copyright © 2018 Yanji Zhang et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Obesity is a worldwide public health problem. Currently, increasing evidence suggests acupuncture and related therapies areeffective for obesity. This network meta-analysis (NMA) was performed to compare the effectiveness of different acupuncture andrelated therapies. We searched potential randomized controlled trials (RCTs) in three international databases. Thirty-four trialsinvolving 2283 participants were included. Pairwise meta-analysis showed that acupuncture and related therapies were superior tolifestyle modification and placebo in reducing weight and body mass index (BMI). Based on decreases in body weight, resultsfrom NMA showed that acupoint catgut embedding (standard mean difference [SMD]: 1.26; 95% credible interval [95% CI],0.46–2.06), acupuncture (SMD: 2.72; 95% CrI, 0.06–5.29), and combination of acupuncture and related theories (SMD: 3.65; 95%CrI, 0.96–6.94) were more effective than placebo. Another NMA result indicated that acupoint catgut embedding (SMD: 0.63;95% CI, 0.25–1.11), acupuncture (SMD: 1.28; 95% CrI, 0.43–2.06), combination of acupuncture and related therapies (SMD: 1.44;95% CrI, 0.64–2.38), and electroacupuncture (SMD: 0.60; 95% CrI, 0.03–1.22) were superior to lifestyle modification in decreasingBMI. Combination of acupuncture and related therapieswas ranked the optimalmethod for both reducingweight andBMI. Furtherstudies will clarify which combination of acupuncture and related therapies is better.

1. Introduction

Obesity, a worldwide public health problem, is described asan adiposity-based chronic disease [1]. Currently, guidelinesrecommended using body mass index (BMI) to classifyindividuals as having obesity (BMI ⩾30 kg/m2) [2]. Based onthe survey conducted previously, the standardized prevalencerates for obesity in adult were 34.9% in United States and17.7% in China [3, 4]. Moreover, it is associated with otherhealth concerns, such as insulin resistance, type 2 diabetes

mellitus, cardiovascular disease, and cancer, which increasedindividuals and societies’ medical burden [5].

Lifestyle modification, pharmacotherapy, and bariatricsurgery are considered the mainstay of therapy for obesity[2]. Although diet and exercise play an essential role in theweight management, their precise mode of action remainscontroversial [6]. Five long-term medicines (naltrexone-bupropion, phentermine-topiramate orlistat, lorcaserin, andliraglutide) have been approved by US Food and DrugAdministration (FDA) for the treatment of obesity [7]. The

HindawiEvidence-Based Complementary and Alternative MedicineVolume 2018, Article ID 9569685, 20 pageshttps://doi.org/10.1155/2018/9569685

2 Evidence-Based Complementary and Alternative Medicine

latest research suggested that phentermine-topiramate wasassociated with the highest possibility of achieving at least 5%weight loss [7]. However, little is known about the long-termsafety profile of pharmacotherapy for weight loss. The effec-tiveness of bariatric procedures for treating obesity has beenreported in several randomized controlled trials (RCTs) [8–10]. Nevertheless, the evidence on cardiovascular disease andmortality remains to be validated [11]. Therefore, it is neces-sary to explore other forms of alternative therapies which areboth safe and effective in preventing gaining weight.

In reviewing the literature, it became evident that acu-puncture and related therapies have been wildly used for obe-sity treatment. As mentioned in the meta-analysis, combina-tion of acupuncture and lifestyle modification is more effec-tive compared with lifestyle modification alone [12]. Resultsof Yeh’s research suggested that ear acupoint stimulation hadremarkable improvements in the anthropometric parametersof Body Weight (BW), BMI, and so on [13]. In addition,another systematic review performed in 2015 has also shownthat clinical efficacy of acupoint catgut embedding therapywas better than that of the control group for simple obesity[14]. However, a major problem is that whether acupunctureor acupuncture-related therapies alone or combined therapyis more effective than lifestyle modification managementremains disputable.

By using the technique of network meta-analysis (NMA),both direct and indirect randomized data can be analyzed,and recommended rankings of different treatments can beprovided [15, 16]. Therefore, we conducted this Bayesian net-work meta-analysis to analyse both direct and indirect com-parisons of acupuncture and related methods for treatingobesity. In this paper, changes in BW, BMI, and the rates ofcomplications of included studies were analyzed.

2. Methods

Our research was conducted following the Preferred Report-ing Items for Systematic Reviews andMeta-Analyses for Net-work Meta-Analysis (PRISMA-NMA) checklist [17] (seeAppendix 1).

2.1. Data Sources and Search Strategy. Three electronic inter-national databases (PubMed/Medline, Embase, and the Co-chrane Library) were searched for potential RCTs (random-ized controlled trials). We identified articles published frominitiation to December 2017 with a limit to studies of RCTand without limitations on language or the form they are

published in. The complete search strategies are shown inAppendix 2.

2.2. Study Selection. Two researchers (XC and HL) inde-pendently identified irrelevant research based on titles andabstracts. Additionally, full-text articles were scanned bythese two researchers to identify eligible studies. All disagree-ments were resolved by consensus and adjudged by a thirdreviewer (TC) if necessary. In case of duplicate citations, themost updated studies were selected for data extraction.

2.3. Inclusion and Exclusion Criteria. The studies included intheNMAmet the following criteria: (1) the study designmustbe a randomized controlled clinical trial (RCT); (2) patientsdiagnosed with simple obesity irrespective of ages and sex asstudy subjects; diagnostic criteria must be clear and inclusionand exclusion criteria were explicit; (3) at least one of thefollowing efficacy outcomes or safety endpoints was included:BW, BMI, and adverse events; (4) participants in the experi-mental group have received acupuncture and related treat-ments (specifically, classical body acupuncture; electroacu-puncture auricular acupoint stimulation; acupoint catgutembedding and warming acupuncture) alone or in combina-tion; (5) English or Chinese language studies.

The following were excluded: (1) self-control and non-RCTs; (2) preclinical studies, systematic reviews, case reports,and meta-analyses; (3) reports without sufficient and clearoriginal data; (4) participants having received other forms ofacupuncture such as transcutaneous electrical nerve stimu-lation or laser acupuncture; (5) duplicate studies and studiesreporting the same results.

2.4. Data Collection and Quality Assessment. According toa standard data collection sheet, two investigators (TC andXZ) independently extracted the following data: (1) maincharacteristics of included randomized controlled trials (i.e.,year of publication, type of intervention, patients charac-teristics, types of outcome, and reported adverse events);(2) details of acupuncture and related interventions (i.e.,frequency and duration of acupuncture sessions, names ofacupuncture points used, and retention time); (3) clinical out-come (i.e., summaries of mean, standard difference, andsample size between treatment groups). In some trials, thechange between baseline and after treatmentwas failed to pre-sent. Using the methods recommended in the CochraneHandbook for Systematic Reviews of Interventions (version5.1) [18], the missing data was estimated using the followingformula:

𝑋𝑐ℎ𝑎𝑛𝑔𝑒 = 𝑋𝑝𝑜𝑠𝑡−𝑡𝑟𝑒𝑎𝑡𝑚𝑒𝑛𝑡 − 𝑋𝑏𝑎𝑠𝑒𝑙𝑖𝑛𝑒 (1)

𝑆𝐷𝑐ℎ𝑎𝑛𝑔𝑒 = √(𝑆𝐷𝑏𝑎𝑠𝑒𝑙𝑖𝑛𝑒)2 + (𝑆𝐷𝑝𝑜𝑠𝑡−𝑡𝑟𝑒𝑎𝑡𝑚𝑒𝑛𝑡)2 − 2 × 𝑟 × 𝑆𝐷𝑏𝑎𝑠𝑒𝑙𝑖𝑛𝑒 × 𝑆𝐷𝑝𝑜𝑠𝑡−𝑡𝑟𝑒𝑎𝑡𝑚𝑒𝑛𝑡 (2)

where r is a correlation coefficient with a value of 0.5[19]. For each included RCT, two researches (XT and XC)

independently assessed their risk of bias by the CochraneCollaboration tool [20]. Bias risks of each study were assessed

Evidence-Based Complementary and Alternative Medicine 3

from six aspects: random sequence generation, allocationconcealment, blinding of participants and investigators,blinding of outcome assessment, incomplete outcome dataaddressed, and selective outcome reporting, while ranked inhigh risk, low risk, and unclear risk.

2.5. Statistical Analysis. Firstly, standard pairwise meta-anal-ysis was initially performed using the Review Manager(Version 5.3, Cochrane Collaboration, Oxford, UK). Wecalculated I-square (I2) test to assess heterogeneity amongRCTs [21]. To be specific, when there was I2 > 50%, they wereanalysed using a random effects model; otherwise, a fixedeffect model was chosen. Subgroup analyses were conductedaccording to the type of acupuncture treatment and the treat-ment of control group. Mean difference (MD) with 95% con-fidence intervals (CI) was used to analyze continuous data.We generated forest plots to illustrate the relative strengthof curative effects.

Second, to indirectly compare the effectiveness amongtreatments of acupuncture and related therapies, we did arandom effects model NMAwithin a Bayesian framework, byusingWinBUGS (Version 1.4.3,MRCBiostatisticsUnit, Cam-bridge, UK) [22, 23]. Models were computed with MarkovchainMonte Carlo (MCMC) simulation methods, using fourchains with overdispersed initial values. We utilized theMarkov chains for 50,000 simultaneous iterations after thefirst 20000 iterations were discarded because they may havean influence on the arbitrary value. In this process, the con-vergence of the model was assessed by the Brooks-Gelman-Rubin (BGR) method; a value of potential scale reductionfactor (PSRF) close to 1 indicated the better convergence [24].The continuous outcome was measured by a standard meandifference (SMD) with a 95% credible intervals (CrI) for in-direct comparisons.

Finally, plot of surface under the cumulative rankingcurve (SUCRA) was generated using the STATA software(Version 13.0; Stata Corporation, College Station, Texas,USA), which indicated the probability of each interventionof being ranked best [25]. In our study, higher SUCRA scoresmean the higher rank of the treatment [15]. A Z value and itscorresponding p-value were calculated, and an R value lessthan 0.05 indicated a statistically significant difference.

3. Results

3.1. Study Search. Weperformed this research onDec 26 2017.As shown in Figure 1, a total of 1050 records were initiallyidentified from the databases. 675 studies left after duplicateswere removed. 577 recordswere excluded after carefully scan-ning titles and abstracts. Finally, 34 trials with 2283 partici-pants were included in our NMA [26–59], covering 8 groups,manual acupuncture; electroacupuncture; auricular acupointstimulation; acupoint catgut embedding; pharmacotherapy;warming acupuncture; lifestyle modification; placebo.

3.2. StudyDescription. Main characteristics of includedRCTswere shown in Table 1. The participants were from Australia[28], the United States [26], Turkey [46], Korea [51], Iran

[36], Egypt [48], and China. Age of participants ranged from15 to 70 years, while the sample size of the studies rangedfrom 12 to 86. Among the included RCTs, there were onefour-arm trials, 5 three-arm trials, and 28 two-arm trials.Fourteen studies compared acupuncture to placebo. Tenstudies compared acupuncture to lifestyle intervention. Sixstudies compared combined therapies to acupuncture alone.Details about acupuncture points used, retention time, fre-quency, and duration of acupuncture sessions were shown inTable 2. In these research, 30 articles [26–30, 32, 34–38, 41–59] reported the weight loss, while 25 articles reported thechange in BMI. The details of mean, standard difference(SD), and sample size between different groups for eligiblestudies are summarized in Appendix 3. The Cochrane risk ofbias assessment was presented in Table 3. Furthermore, thenetwork plot of included comparisons was shown in Figure 2.

3.3. Pairwise Meta-Analyses

3.3.1. Body Weight. A direct pairwise meta-analysis showedthat acupuncture and related therapies showed a greater BWreduction than lifestyle modification (MD: 1.66; 95% Confi-dence interval, 0.63to2.70) and placebo (MD: 1.15; 95% CI,0.67to1.63). When compared to acupuncture, combinationof acupuncture and related theories showed a marginallystronger effect in weight loss (MD: 1.56; 95% CI, 0.07to3.05).There was no statistically significant difference betweencombination of acupuncture and related theories and phar-macotherapy in their effectiveness in BW (MD: 2.44; 95%CI,-1.98to6.86). (Table 4)

BMI. As for the comparison in reducing BMI, acupunctureand related therapies were found to be marginally superiorto lifestyle modification (MD: 1.17; 95% CI, 0.09to2.26) andplacebo (MD: 0.57; 95%CI, 0.40to0.74).The remaining directcomparisons did not show significant differences (Table 4).

3.4. Network Meta-Analysis

3.4.1. Body Weight. The NMA showed that all treatmentsother than acupuncture combined lifestyle modification weremore efficacious than lifestyle modification. Three treat-ments were significantly more effective than placebo. Specif-ically, acupoint catgut embedding (SMD: 1.26; 95% credibleinterval, 0.46to2.06), acupuncture (SMD: 2.72; 95% CrI,0.06to5.29), and combination of acupuncture and relatedtherapies (SMD: 3.65; 95% CrI, 0.96to6.94). Furthermore,moxibustion with warming needle was associated with asignificantly improvement than lifestyle modification (SMD:-5.24; 95% CrI, -10.15to-0.55) (Table 5).

3.4.2. BMI. Four treatments showed superiority overplacebo, including acupoint catgut embedding (SMD: 1.31;95% CrI, 0.36to2.06), acupuncture (SMD: 1.94; 95% CrI,0.83to3.00), combination of acupuncture and related theories(SMD: 3.65; 95% CrI, 0.96to6.94), and electroacupuncture(SMD: 1.28; 95% CrI, 0.43to2.11). Four treatments weresignificantly more effective than lifestyle modification,including acupoint catgut embedding (SMD: 0.63; 95% CI,

4 Evidence-Based Complementary and Alternative Medicine

Records identified through database searching

(n = 1050)Sc

reen

ing

Incl

uded

Elig

ibili

tyId

entifi

catio

n

Recordsa�er duplicates removed(n =675)

Records excluded a�er readingtitles and abstracts (n = 577)

Full-text articles assessedfor eligibility

(n =98)

Full-text articles excluded, withreasons(n =63)

Duplicates(n =8)Non-RCTs(n=23)Non-Acupuncture(n=12)Obesity with complications(n = 8)Not included outcome (n = 7)Other(n = 6)

Studies included in quantitative synthesis

(meta-analysis)(n =34)

Figure 1: PRISMA flow chart.

AAS

ACE

AR+LMAcupuncture

Combined theories

EA

LM

Pharmacotherapy

Placebo

WA

AAS

ACE

AR+LMAcupuncture

Combined theories

EA

LMPharmacotherapy

Placebo

BMIBody weight

Figure 2: Network plot. BMI: body mass index; LM: lifestyle modification; AAS: auricular acupoint stimulation; EA: electroacupuncture;ACE: acupoint catgut embedding; WA: warming acupuncture; AR: acupuncture and related therapies; combined therapies: combination ofacupuncture and related therapies.

Evidence-Based Complementary and Alternative Medicine 5

Table1:Maincharacteris

ticso

fincludedrand

omized

controlledtrials.

Stud

yID

andCou

ntry

Samples

izeR

/AAge:m

ean(SD)o

rrange

R/A

Interventio

nCon

trol

Adversee

ventsreported

R/A

Type

ofou

tcom

es

Allisonetal.[17]1995,USA

35/34

19-7

0AAS

Placebo

Redn

ess,pain,bleeding

BW,

Hsu

etal.[18]2

005,Taiwan

24/22

41.5(11.2

)/41.0(10.0)

EALM

Ecchym

osis(2),a

bdom

inal

discom

fort(1)

/Non

eBW

,BMI

Richards

etal.[19]1998,Au

stralia

28/32

44.1(11.7

)/43.0(13.6)

AAS

Placebo

intercurrent

illnessand

discon

tinued(1)/N

one

BW

Hee

tal.[20]

2008,C

hina

40/40

18-5

0Com

binedtherapies#

Pharmacotherapy

NR

BW,B

MI

Lietal.[21]2

006,Ch

ina

26/30

16.00(1.3

8)/16

.00(1.9

5)EA

LMNR

BMI

29/30

15.00(2.04

)/16.00(1.9

5)AAS

Tong

etal.[22]2

011,Ch

ina

76/42

35.08(9.3

1)/34.60

(8.55)

Acup

uncture

Placebo

Adversee

ventsV

AS

BMI

Hsu

etal.[23]2

009,Taiwan

23/22

40.0(10.5)/39.4

(13.6)

AAS

Placebo

Minor-in

flammation(1),

mild

tend

erness(7)/mild

tend

erness(2)

BW,B

MI

Hsie

hetal.[24]2

010,Taiwan

26/26

18-2

0AAS

Placebo

NR

BMI

Hsie

hetal.[25]2

011,Taiwan

27/28

18-2

0AAS

Placebo

NR

BWAb

dietal.[26]2

012,Iran

86/83

37.29(1.0

)/38.73(

1.1)

AAS

Placebo

Non

eBW

,BMI

Darband

ietal.[27]

2012,Iran

43/43

37.57(9.2

6)/37.6

5(9.7

1)AR+

LMPlacebo

Non

eBW

,BMI,

Hee

tal.[28]

2012,C

hina

30/30

18-54

AR+

LMLM

NR

BW,B

MI

Lien

etal.[29]2

012,Taiwan

24/23

39.2(11.6

)/40

.7(9.7)

AAS

Placebo

Dizziness(1)

/Non

eBW

,BMI

Darband

ietal.[30]

2014,Iran

20/20

38.0(0.9)/38.0(1.3)

EAPlacebo(EA

)Non

eBW

,BMI

20/20

39.0(1.8)/37.9(1.5)

AAS

Placebo(AAS)

Yehetal.[31]2

015,Taiwan

36/34

29.9(7.7)/32.8(9.5)

EAPlacebo

NR

BMI

Chen

etal.[32]2

007,Ch

ina

40/40

43.1(13.6)/44

.6(10.3)

ACE

Acup

uncture

NR

BW,B

MI

Huang

etal.[33]2

011,Ch

ina

30/30

NR

ACE

EANR

BW,B

MI

Tang

etal.[34]2

009,Ch

ina

33/32

21-54/22-55

Com

binedtherapies

EANR

BW,B

MI

6 Evidence-Based Complementary and Alternative Medicine

Table1:Con

tinued.

Stud

yID

andCou

ntry

Samples

izeR

/AAge:m

ean(SD)o

rrange

R/A

Interventio

nCon

trol

Adversee

ventsreported

R/A

Type

ofou

tcom

es

Shietal,[35]

2006

,China

40/42

17-49/18-51

Com

binedtherapies

EANR

BW,B

MI

Hsu

etal.[36]2

005,Taiwan

22/20

40.0(11.5

)/41.3(9.9)

EALM

mild

Ecchym

osis(3),

abdo

minal

discom

fort(1)

/Non

eBW

,BMI

Guceletal.[37]2

012,Tu

rkey

20/20

34.6±6.

3/36.8±7.

8Ac

upun

cture

Placebo

NR

BW,B

MI

Dengetal.[38]2

014,Ch

ina

30/30

32(7)/33(7)

Com

binedtherapies

Acup

uncture

NR

BW30/30

32(7)/33(8)

ACE

Hassanetal.[39]2

014,Eg

ypt

21/30

45.00(9.32

)/43.47(9.59)

AR+

LMLM

NR

BW,B

MI

Hee

tal.[40]

2014,C

hina

28/28

NR

Com

binedtherapies

Acup

uncture

NR

BW,B

MI

Wangetal.[41]2

013,Ch

ina

45/45

31(10)/32(12)

EAAc

upun

cture

NR

BMI

Sujung

etal.[42]2

014,SouthKo

rea

22/15

34.7(11.9

)/42.7(10.2)

AAS

Placebo

NR

BW,B

MI

Buetal.[43]2

007,Ch

ina

32/23

32.1(1.1)/33.4(1.3)

Com

binedtherapies

Acup

uncture

NR

BW,B

MI

Shietal.[44]

2005,C

hina

36/32

19∼58

/18∼56

WA

EANR

BWYang

etal.[45]2

010,Ch

ina

31/30

18∼42

/18∼48

AR+

LMLM

NR

BW

Cabiogluetal.[46]2

005,Tu

rkey

22/12

39.8(5.3)/43.3(4.3)

EAPlacebo

NR

BW22/21

39.8(5.3)/42.7(3.9)

LM

Cabiogluetal.[47]2

006,Tu

rkey

20/15

42.1(4.4)/41.8

(4.6)

EAPlacebo

NR

BW20/15

42.1(4.4)/42.9(4.3)

LM

Cabiogluetal.[48]2

008,Tu

rkey

20/15

40.55(

5.30)/41.47(4.61)

EAPlacebo

NR

BW20/23

40.55(

5.30)/42.91(4.02)

LMDarband

ietal.[49]

2013,Iran

42/44

36.50(9.26)/36.48

(8.69)

AR+

LMPlacebo

NR

BW,B

MI

Fogartye

tal.[50]

2015,A

ustralia

19/16

>18AR+

LMPlacebo

NR

BMI

BW:bod

yweight;BM

I:bo

dymassind

ex;L

M:lifesty

lemod

ificatio

n;AAS:auric

ular

acup

oint

stimulation;

EA:electroacup

uncture;AC

E:acup

oint

catgut

embedd

ing;WA:w

armingacup

uncture;AR:

acup

uncture

andrelatedtherapies;#com

binatio

nof

acup

unctureandrelatedtherapies.

Evidence-Based Complementary and Alternative Medicine 7

Table2:Descriptio

nsof

theincludedacup

uncturea

ndrelatedtherapies.

Stud

yID

(Cou

ntry)

Styleo

facupu

ncture

Nam

esof

acup

uncturep

ointsu

sed

Retentiontim

eFrequency&

duratio

nof

Acup

uncturesessio

nsAllisonetal.1995,USA

AAS

NR

2-3m

in3sessions

daily

for12we

eks

Hsu

etal.200

5,Taiwan

EA

Qiai(R

EN9),Shu

ifen(RE

N9)

Shuidao(ST

28),Siman(K

14)

Zusanli(S

T26),Fenglon

g(ST

40)

Sang

injao(SP

6)

40min

2sessions

weeklyfor6

weeks

Richards

etal.1998,

Austr

alia

AAS

Shenmen(TF4

),Stom

ach(CO4)

15-20m

in2sessions

daily

for4

weeks

Hee

tal.2008,C

hina

Com

binedtherapies#

Eara

cupressure:

Shenmen(TF4

),Neifenm

i(CO18),

Pi(C

O13),Wei(C

O14),

Sanjiao(CO17),Dachang

(CO7),

Naodian

Body

acup

uncture:

Tianshu(ST

25),Guanyuan(RN

4)Sanyinjiso(SP

9),Fenglon

g(ST

40)

Zusanli(S

T36)

Eara

cupressure:3days

Body

acup

uncture:3

0min

Eara

cupressure:1sessionevery3

days

with

atotalof

10sessions

Body

acup

uncture:Th

efirst5

days

oftre

atment1

time,5days

after

treatment1,1

mon

th,for

acou

rseo

ftre

atment.

Lietal.200

6,Ch

ina

EA

Sang

injao(SP

6),T

ianshu

(ST2

5)Zu

sanli(S

T36),Q

uchi(LI11

)Feng

long

(ST4

0),N

eitin

g(ST

44)

Zhon

gwan(C

V12),Pishu(BL

20)

Shenshu(BL

23),Qihai(C

V6)

Yinlingquan(SP

9),

Shangjux

u(ST

37)T

aichon

g(LR

3)

10min

1sessio

ndaily

with

atotalof

60sessions,2

days

restin-betwe

en10

sessions

AAS

Hun

gerp

oint

Pizhixia(AT4

)Sh

enmen(TF4

),Sh

enshangxian(TG

2P)

Sanjiao(CO17),Pi(C

O13)

Wei(C

O14),Fei(C

O14)

Kou(CO1),D

achang

(CO7)

Zhichang

xidu

an(H

X2)

15-20m

in1sessio

ndaily

with

atotalof

10sessions

for10we

eks,2dayrest

in-betwe

en10

sessions

Tong

etal.2011,Ch

ina

Acup

uncture

Zhon

gwan(C

V12),Zh

ongji(C

V3)

Daheng(SP

15),Xiaw

an(C

V10)

Shim

en(C

V5),T

ianshu

(ST2

5)Liangqiu(ST3

4),Z

usanli(ST

36)

Yinlingquan(SP

9)

30min

1sessio

neveryo

ther

dayfora

total

of5we

eksw

ith12

sessions

Hsu

etal.200

9,Taiwan

AAS

Hun

gerp

oint,Shenm

enpo

int(T

F4)

Stom

achpo

int(C

O4),

Endo

crinep

oint(C

O18)

3days

2sessions

weeklyfora

totalof6

weeksw

ith12

sessions

Hsie

hetal.2010,Taiwan

AAS

NR

2/3d

ays

1sessio

nwe

eklyfor10sessions

Hsie

hetal.2011,Taiwan

AAS

NR

NR

1sessio

nwe

eklyfora

totalofeight

weeks

8 Evidence-Based Complementary and Alternative Medicine

Table2:Con

tinued.

Stud

yID

(Cou

ntry)

Styleo

facupu

ncture

Nam

esof

acup

uncturep

ointsu

sed

Retentiontim

eFrequency&

duratio

nof

Acup

uncturesessio

ns

Abdi

etal.2012,Iran

AAS

Shenmen(TF4

),Stom

ach(CO4)

Hun

gerp

oint

Mou

th(C

O1)

Centre

ofear(HX1),Sanjiao(CO17)

3days

Twicea

week

fora

totalof6

weeks

Darband

ietal.2012,Iran

AAS

Shenmen(TF4

),Stom

ach(CO4)

Hun

gerp

oint

Mou

th(C

O1)

Centre

ofear(HX1),Sanjiao(CO17)

3days

Twicea

week

fora

totalof6

weeks

Hee

tal.2012,C

hina

AAS

Hun

gerp

oint

Stom

ach(CO4)

Spleen(C

O14),LargeIntestin

e(CO7)

Endo

crine(CO18),Sh

enmen(TF4

)3d

ays

3tim

esad

ayfor4

weeks

Lien

etal.2012,Taiwan

AAS

Shenmen

point(T

F4),Stom

ach

point(C

O4)

Hun

gerp

oint,E

ndocrin

epo

int(C

O18)

NR

3sessio

nwe

eklywith

atotalof

12sessions

for4

weeks

Placebo

Shenmen

point(T

F4),Stom

ach

point(C

O4)

Hun

gerp

oint,E

ndocrin

epo

int(C

O18)

NR

3sessions

weeklywith

atotalof

12sessions

for4

weeks

Darband

ietal.2014,Iran

EA

Tianshu(ST-25),Weidao(GB2

8)Zh

ongw

an(REN

12),Shuifen(RE

N9)

Guanyuan(RE

N4),Sanyinjiao(SP

6)Quchi(LI11),Fenlong

(ST4

0)Qihai(REN

6),Y

inlin

gquan(SP9

)

20min

2sessions

weeklyfora

totalof6

weeks

AAS

Shenmen

(TF4

),Stom

ach(C

O4)

Hun

gerp

oint,M

outh

(CO1)

Centero

fear

(HX1),Sanjiao(C

O17)

3days

2sessions

weeklyfora

totalof6

weeks

Yehetal.2015,Taiwan

EASh

enmen

(TF4

),Stom

achCO4)

Endo

crine(CO18)

Hun

gerp

oint

20min

NR

Chen

etal.200

7,Ch

ina

ACE

Liangqiu(ST3

4),Z

hong

wan(C

V12)

Tianshu(ST

25),Shuifen(CV

9)Feng

long

(ST4

0)Awe

ek1sessio

nwe

eklywith

atotalof

30sessions

for4

weeks

Acup

uncture

Liangqiu(ST3

4),Z

hong

wan(C

V12)

Tianshu(ST

25),Shuifen(CV

9)Feng

long

(ST4

0)45

min

Thefi

rst5

days

are1

times

aday,

and1tim

eafter5

days,1

mon

this1

course

oftre

atment.

Huang

etal.2011,Ch

ina

ACE

One

setisT

ianshu

(ST2

5)Zh

ongw

an(C

V12),Guanyuan(CV

4)Zu

sanli(S

T36),W

eishu(BL

21)

Ashixue

24ho

ur1sessio

nwe

eklywith

atotalof

7sessions

for6

0days

EA

Zhon

gwan(C

V12),Tianshu(ST

25)

Daheng(SP

15),Shuifen(CV

9)QIhai(C

V6),G

uanyuan(CV

4)Zu

sanli(S

T36),A

shixue

30min

3sessions

weeklywith

atotalof

12sessions

for6

0days

Evidence-Based Complementary and Alternative Medicine 9Ta

ble2:Con

tinued.

Stud

yID

(Cou

ntry)

Styleo

facupu

ncture

Nam

esof

acup

uncturep

ointsu

sed

Retentiontim

eFrequency&

duratio

nof

Acup

uncturesessio

ns

Tang

etal.200

9,Ch

ina

Com

binedtherapies

EA:

Zhon

gwan(C

V12),Xiaw

an(C

V10)

Guanyuan(CV

4),T

ianshu

(ST2

5)Shuifen(CV

9),Sanyinjiao(SP

6)Zu

sanli(S

T36),X

uehai(S

P10)

Xinshu

(BL15),G

eshu

(BL17)

Pishu(BL

20)

ACE:

Zhon

gwan(C

V12),Tianshu(ST

25)

Qihai(C

V6),T

ianshu

(ST2

5)Liangqiu(ST3

4),Z

usanli(ST

36)

Gon

gsun

(SP4

),Xinshu

(BL15)

Pishu(BL

20)

EA:30m

in

EA:Th

efirst3

days

are1

times

aday,

and1tim

eafte

r3days,15days

is1

course

oftre

atment.

ACE:Afte

rthe

firstacup

oint

catgut

embedd

ingfor3

consecutivetim

es,

theintervalisb

uriedforthe

second

timea

fter15days,and

the

acup

unctureisp

erform

edforthe

third

timea

fterthe

endof

the

treatmentp

eriod.

EA

Zhon

gwan(C

V12),Xiaw

an(C

V10)

Guanyuan(CV

4),T

ianshu

(ST2

5)Shuifen(CV

9),Sanyinjiao(SP

6)Zu

sanli(S

T36),X

uehai(S

P10)

Xinshu

(BL15),G

eshu

(BL17)

Pishu(BL

20)

30min

Thefi

rst3

days

are1

times

aday,

and1tim

eafte

r3days,15days

is1

course

oftre

atment.

Shietal.2006

,China

Com

binedtherapies

Zhon

gwan(C

V12),Xiaw

an(C

V10)

Qihai(C

V6),Z

hong

ji(CV

3)Tianshu(ST

25),Daheng(SP

15)

Liangm

en(ST2

1),

Huaroum

en(ST2

4)Shuidao(ST

28),Quchi(C

V6)

Zhigou

(TE6

),Hegu(LI4)

Liangqiu(ST3

4),Z

usanlli(ST3

6)Sh

angjux

u(ST

37),Feng

long

(ST4

0)Sanyinjiao(SP

6),G

ongsun

(SP4

)Neitin

g((ST4

4)

30min

EA:Th

efirst3

days

are1

times

aday,

and1tim

eafte

r3days,15days

is1

course

oftre

atment.

ACE:

Afte

rthe

firstacup

oint

catgut

embedd

ingfor3

consecutivetim

es,

theintervalisb

uriedforthe

second

timea

fter15days,and

the

acup

unctureisp

erform

edforthe

third

timea

fterthe

endof

the

treatmentp

eriod.

EA

Zhon

gwan(C

V12),Xiaw

an(C

V10)

Qihai(C

V6),Z

hong

ji(CV

3)Tianshu(ST

25),Daheng(SP

15)

Liangm

en(ST2

1),

Huaroum

en(ST2

4)Shuidao(ST

28),

Quchi(C

V6)

Zhigou

(TE6

),Hegu(LI4)

Liangqiu(ST3

4),Z

usanlli(ST3

6)Sh

angjux

u(ST

37),Feng

long

(ST4

0)Sanyinjiao(SP

6),G

ongsun

(SP4

)Neitin

g((ST4

4)

30min

Thefi

rst3

days

are1

times

aday,

and1tim

eafte

r3days,15days

is1

course

oftre

atment.

Hsu

etal.200

5,Taiwan

EA

Qihai(REN

-6),Shuifen(REN

-9)

Shuidao(ST-28),Siman

(K-14)

Zusanli(ST

-26),Fenglon

g(ST

-40)

Sang

injao(SP-6)

40min

2sessions

weeklywith

atotalof

12sessions

for6

weeks

10 Evidence-Based Complementary and Alternative Medicine

Table2:Con

tinued.

Stud

yID

(Cou

ntry)

Styleo

facupu

ncture

Nam

esof

acup

uncturep

ointsu

sed

Retentiontim

eFrequency&

duratio

nof

Acup

uncturesessio

ns

Guceletal.2012,Tu

rkey

Acup

uncture

Hegu(LI4),Shenm

en(H

T7)

Zusanli(S

T36),N

eitin

g(ST

44)

Sanyinjiao(SP

6)20

min

2sessions

weeklywith

atotalof

10sessions

for5

weeks

Dengetal.2014,Ch

ina

Com

binedtherapies

Zhon

gwan

(CV12),Xiaw

an(C

V10)

Qihai(C

V6),G

uanyuan(

CV4)

Huaroum

en(ST24),Wailin

g(S

T26)

Daheng(SP15),Tianshu(ST25)

Yinjiao(C

V7),Z

higou(TE6)

Zusanll(ST

36)

NR

Acup

uncture:1

sessionevery3

days

with

atotalof

21sessions

for4

weeks,3days

restbetweenevery

session

Acup

oint

catgut

Embedd

ing:1sessio

nwe

eklywith

atotalof3

sessions

for3

weeks

Acup

uncture

Zhon

gwan

(CV12),Xiaw

an(C

V10)

Qihai(C

V6),G

uanyuan(

CV4)

Huaroum

en(ST24),Wailin

g(S

T26)

Daheng(SP15),Tianshu(ST25)

30min

1sessio

nevery3

days

with

atotalof

21sessions

for4

weeks,3days

rest

betweeneverys

essio

n

Acup

oint

catgut

embedd

ing

Zhon

gwan

(CV12),Tianshu(ST25)

Yinjiao(C

V7),Z

higou(TE6)

Guanyuan(

CV4),Z

usanli(ST36)

NR

1sessio

nwe

eklywith

atotalof

3sessions

for3

weeks

Hassanetal.2014,Eg

ypt

AR

NR

NR

NR

Hee

tal.2014,C

hina

AR

NR

NR

NR

acup

uncture

Tianshu(ST2

5),Liang

men(ST2

1)Daheng(SP15),Z

usanli(ST3

6)Sanyinjiao(SP

6),Q

uchi

(LI11

)Zh

igou

(SJ6),Zh

ongw

an(RN12)

Qihai(RN06

)

30min

1sessio

ndaily

with

atotalof

21sessions

for3

weeks

Wangetal.2013,Ch

ina

EA

Neitin

g(ST

44),Sh

angjux

u(ST

37)

Xiaju

xu(ST3

9),Fenglon

g(ST

40)

Tianshu(ST

25),Zu

sanli(S

T36)

Quchi(LI11

)

30min

1sessio

nevery2days

with

atotalof

12sessions

for3

weeks

Acup

uncture

Neitin

g(ST

44),Sh

angjux

u(ST

37)

Xiaju

xu(ST3

9),Fenglon

g(ST

40)

Tianshu(ST

25),Zu

sanli(S

T36)

Quchi(LI11

)

30min

1sessio

nevery2days

with

atotalof

12sessions

for3

weeks

Sujung

etal.2014,South

Korea

AAS

Shen-m

en(TF4

),Stom

ach(CO4)

Spleen(C

O13),Hun

gerp

oint

Endo

crine(C0

18)

NR

1sessio

nwe

eklywith

atotalof

8sessions

for8

weeks

Evidence-Based Complementary and Alternative Medicine 11

Table2:Con

tinued.

Stud

yID

(Cou

ntry)

Styleo

facupu

ncture

Nam

esof

acup

uncturep

ointsu

sed

Retentiontim

eFrequency&

duratio

nof

Acup

uncturesessio

ns

Buetal.200

7,Ch

ina

Com

binedtherapies

Acup

uncture:

Tianshu(ST

25),Guanyuan(CV

4)Zu

sanli(S

T36),Fenglon

g(ST

40)

Sanyinjiao(SP

6)AAS:

Shenmen(TF4

),En

docrine(C0

18)

Spleen(C

O13),Stom

ach(CO4)

Dachang

(CO7),Sanjiao(CO17

)Naodian

Acup

uncture:3

0min

eara

cupressure:1day

1sessio

neveryd

aywith

atotalof

10sessions

for6

weeks,1w

eekrest

in-betwe

en10

sessions.

Acup

uncture

Tianshu(ST

25),Guanyuan(CV

4)Zu

sanli(S

T36),Fenglon

g(ST

40)

Sanyinjiao(SP

6)30

min

1sessio

neveryd

aywith

atotalof

10sessions

for6

weeks,1w

eekrest

in-betwe

en10

sessions.

Shietal.2005,C

hina

Warmingacup

uncture

Zhon

gwan(C

V12),Shuifen(CV

9)Qihai(C

V6),Z

hong

ji(CV

3)Tianshu(ST

25),Shuidao(ST

28)

Neigu

an(PC6

),Hegu(LI4)

Xuehai(SP10),Z

usanli(ST

36)

Feng

long

(ST4

0),Sanyinjiao(SP

6)

40min

1sessio

neveryd

aywith

atotalof

15sessions

for4

weeks

EA

Zhon

gwan(C

V12),Shuifen(CV

9)Qihai(C

V6),Z

hong

ji(CV

3)Tianshu(ST

25),Shuidao(ST

28)

Neigu

an(PC6

),Hegu(LI4)

Xuehai(SP10),Z

usanli(ST

36)

Feng

long

(ST4

0),Sanyinjiao(SP

6)

40min

1sessio

neveryd

aywith

atotalof

15sessions

for4

weeks

Yang

etal.2010,Ch

ina

AR

Zhon

gwan(C

V12),Tianshu(ST

25)

Guanyuan(CV

4),Z

usanli(ST

36)

Feng

long

(ST4

0),Y

inlin

gquan(SP

9)Sanyinjiao(SP

6),P

ishu(BL

20)

Weishu(BL

21),Ashixue

30min

1sessio

ndaily

with

atotalof

15sessions

for7

weeks,3days

rest

betweeneverys

essio

n

Cabiogluetal.200

5,Tu

rkey

EA

Body

points:

Hegu(LI

4),T

ianshu

(ST25)

Quchi(LI11),Z

usanli(ST

36)

Neitin

g(ST

44

30min

Body

EAwas

perfo

rmed

everyday,

andEA

was

perfo

rmed

everyo

ther

day

Cabiogluetal.200

6,Tu

rkey

EABo

dypo

ints:

Quchi(LI11),Z

usanli(ST

36)

Neitin

g(ST

44)

30min

Body

EAapplicationwas

perfo

rmed

daily

for2

0days,and

EAwas

appliedto

each

earo

nalternating

days

12 Evidence-Based Complementary and Alternative Medicine

Table2:Con

tinued.

Stud

yID

(Cou

ntry)

Styleo

facupu

ncture

Nam

esof

acup

uncturep

ointsu

sed

Retentiontim

eFrequency&

duratio

nof

Acup

uncturesessio

ns

Cabiogluetal.200

8,Tu

rkey

EA

Body

points:

Hegu(LI

4),Q

uchi(LI11)

Tianshu(ST

25)Zusanli(ST

36)

Taito

ng(Liv3),N

eitin

g(ST

44)

30min

Body

EAapplicationwas

perfo

rmed

daily

for2

0days,and

EAwas

appliedto

each

earo

nalternating

days

Darband

ietal.2013,Iran

AR

Inrerventio

ngrou

p:Tianshu(ST

25),Weidao(GB28)

Zhon

gwan(RN12),Shuifen(RN

9)Guanyuan(RN

4),Sanyinjiao(SP

6)Ex

cessgrou

p:Quchi(LI11),Fenglon

g(ST

40)

Deficiency

grou

p:Qihai(RN6),Y

inlin

gquan(SP

9)

20min

Twotre

atmennt

perw

eekfora

total

of6we

eks(12

treatments)

Fogartye

tal.2015,

Austr

alia

AR

Hegu(LI

4),Q

uchi(LI11)

Zusanli(S

T36),Neitin

g(ST

44)

Taicho

ng(LR3)

Auric

ular

acup

uncture:

Shenmen(TF4

)

NR

NR

LM:lifesty

lemod

ificatio

n;AAS:auric

ular

acup

oint

stimulation;

EA:electroacup

uncture;AC

E:acup

oint

catgut

embedd

ing;WA:w

armingacup

uncture;AR:

acup

unctureandrelatedtherapies;#com

binatio

nof

acup

unctureandrelatedtherapies.

Evidence-Based Complementary and Alternative Medicine 13

Table3:Risk

ofbias

assessment.

Stud

yRa

ndom

sequ

ence

generatio

nAllo

catio

nconcealm

ent

Blinding

ofparticipants

andinvestigators

Blinding

ofou

tcom

eassessment

Incompleteo

utcome

dataaddressed

Selectiveo

utcome

repo

rting

Allisonetal.1995,USA

Unclear

risk

Unclear

risk

Highris

kLo

wris

kLo

wris

kUnclear

risk

Hsu

etal.200

5,Taiwan

Unclear

risk

Unclear

risk

Highris

kLo

wris

kLo

wris

kUnclear

risk

Richards

etal.1998,Au

stralia

Unclear

risk

Lowris

kHighris

kLo

wris

kLo

wris

kUnclear

risk

Hee

tal.2008,C

hina

Unclear

risk

Unclear

risk

Highris

kLo

wris

kLo

wris

kUnclear

risk

Lietal.200

6,Ch

ina

Lowris

kUnclear

risk

Highris

kLo

wris

kLo

wris

kUnclear

risk

Tong

etal.2011,Ch

ina

Unclear

risk

Unclear

risk

Highris

kLo

wris

kLo

wris

kUnclear

risk

Hsu

etal.200

9,Taiwan

Unclear

risk

Unclear

risk

Highris

kLo

wris

kLo

wris

kUnclear

risk

Hsie

hetal.2010,Taiwan

Unclear

risk

Unclear

risk

Highris

kLo

wris

kHighris

kUnclear

risk

Hsie

hetal.2011,Taiwan

Unclear

risk

Unclear

risk

Highris

kLo

wris

kLo

wris

kUnclear

risk

Abdi

etal2012,Iran

Unclear

risk

Unclear

risk

Highris

kLo

wris

kHighris

kUnclear

risk

Darband

ietal2012,Iran

Unclear

risk

Unclear

risk

Highris

kLo

wris

kLo

wris

kUnclear

risk

Hee

tal2012,Ch

ina

Unclear

risk

Unclear

risk

Highris

kLo

wris

kUnclear

risk

Unclear

risk

Lien

etal2012,Taiwan

Lowris

kLo

wris

kHighris

kLo

wris

kHighris

kUnclear

risk

Darband

ietal2014,Iran

Lowris

kLo

wris

kHighris

kLo

wris

kLo

wris

kUnclear

risk

Yehetal.2015,Taiwan

Lowris

kLo

wris

kHighris

kLo

wris

kHighris

kUnclear

risk

Chen

etal.200

7,Ch

ina

Lowris

kUnclear

risk

Highris

kLo

wris

kLo

wris

kUnclear

risk

Huang

etal.2011,Ch

ina

Unclear

risk

Unclear

risk

Highris

kLo

wris

kLo

wris

kUnclear

risk

Tang

etal.200

9,Ch

ina

Highris

kUnclear

risk

Highris

kLo

wris

kLo

wris

kUnclear

risk

Shietal,2006

,China

Lowris

kUnclear

risk

Highris

kLo

wris

kUnclear

risk

Unclear

risk

Hsu

etal.200

5,Taiwan

Lowris

kUnclear

risk

Highris

kLo

wris

kLo

wris

kUnclear

risk

Guceletal.2012,Tu

rkey

Lowris

kUnclear

risk

Highris

kLo

wris

kLo

wris

kUnclear

risk

Dengetal.2014,Ch

ina

Unclear

risk

Unclear

risk

Highris

kLo

wris

kLo

wris

kUnclear

risk

Hassanetal.2014,Eg

ypt

Unclear

risk

Unclear

risk

Highris

kLo

wris

kLo

wris

kUnclear

risk

Hee

tal.2014,C

hina

Lowris

kUnclear

risk

Highris

kLo

wris

kLo

wris

kUnclear

risk

Wangetal.2013,Ch

ina

Highris

kUnclear

risk

Highris

kLo

wris

kLo

wris

kUnclear

risk

Sujung

etal.2014,SouthKo

rea

Lowris

kLo

wris

kHighris

kLo

wris

kLo

wris

kUnclear

risk

Buetal.200

7,Ch

ina

Lowris

kUnclear

risk

Highris

kLo

wris

kLo

wris

kUnclear

risk

Shietal.2005,C

hina

Lowris

kUnclear

risk

Highris

kLo

wris

kLo

wris

kUnclear

risk

Yang

etal.2010,Ch

ina

Highris

kUnclear

risk

Highris

kLo

wris

kLo

wris

kUnclear

risk

Cabiogluetal.200

5,Tu

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risk

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risk

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wris

kUnclear

risk

Cabiogluetal.200

6,Tu

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risk

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risk

Highris

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wris

kLo

wris

kUnclear

risk

Cabiogluetal.200

8,Tu

rkey

Unclear

risk

Unclear

risk

Highris

kLo

wris

kLo

wris

kUnclear

risk

Darband

ietal.2013,Iran

Lowris

kUnclear

risk

Highris

kLo

wris

kLo

wris

kUnclear

risk

Fogartye

tal.2015,A

ustralia

Unclear

risk

Lowris

kHighris

kLo

wris

kLo

wris

kUnclear

risk

14 Evidence-Based Complementary and Alternative Medicine

Table 4: Pairwise meta-analyses.

Comparison Pairwise OR (95% CI) Number of patients Number of studies Heterogeneity testI2 (%) p value

Body weightAR vs. LM 1.66(0.63 to 2.70) 496 10 55 0.02AR vs. placebo 1.15(0.67 to 1.63) 833 14 65 0.0004Combines therapies vs. PHA 2.44(-1.98 to 6.86) 80 1 - -Acupuncture vs. related therapies 0.25(0.00 to 0.49) 413 6 0 0.73Combines therapies vs. acupuncture 1.56(0.07 to 3.05) 378 6 99 <0.00001

BMIAR vs. LM 1.17(0.09 to 2.26) 314 6 74 0.002AR vs. placebo 0.57(0.40 to 0.74) 830 12 63 0.002Combines therapies vs. PHA 0.48(-0.90 to 1.86) 80 1 - -Acupuncture vs. related therapies 0.13(-0.06 to 0.32) 325 5 0 0.8Combines therapies vs. acupuncture 0.77(-0.37 to 1.92) 158 4 88 <0.00001

BMI: body mass index; LM: lifestyle modification; PHA: pharmacotherapy; AR: acupuncture and related therapies.

0.25to1.11), acupuncture (SMD: 1.28; 95% CrI, 0.43to2.06),combination of acupuncture and related theories (SMD: 1.44;95% CrI, 0.64to2.38), and electroacupuncture (SMD: 0.60;95% CrI, 0.03to1.22). Also, the combination of acupunctureand related theories and acupuncture alone were bothsuperior to the acupuncture combined lifestyle modificationin their ability to reduce body mass index (SMD = -1.76, 95%CrI =−2.96 to −0.62; SMD = −1.59, 95% CrI = −2.71to −0.34)(Table 5).

3.5. Ranking

3.5.1. Body Weight. Ranking of the different treatment meth-ods was displayed Figure 3. The results suggested that, onthe aspect of weight loss, combination of acupuncture andrelated therapies was ranked the optimal method, the best,(88.7%), followed by moxibustion with warming needle(87.8%), manual acupuncture (70.5%), acupoint catgut em-bedding (ACE,62.1%), auricular acupoint stimulation (AAS,48.3%), electro acupuncture (EA,46.3%), pharmacotherapy(41.9%), acupuncture combined lifestyle modification (AR+LM,31.2%), placebo acupuncture/sham acupuncture (16.8%),and lifestylemodification (LM,6.4%)whichwas ranked as theworst.

3.5.2. BMI. The results suggested that, on the aspect of BMI,combination of acupuncture and related therapies was rankedthe optimal method, the best, (90.2%), followed by manualacupuncture (83.3%), pharmacotherapy (64.7%), acupointcatgut embedding (58.6%), auricular acupoint stimulation(55.7%), electroacupuncture (52.1%), placebo acupuncture/sham acupuncture (25.1%), acupuncture combined lifestylemodification (16.9%), and lifestylemodification (3.4%)whichwas ranked as the worst.

3.6. Inconsistency Assessment

3.6.1. Body Weight. The Z test illustrates the inconsistencyof the NMA specifically (Appendix 4). For the inconsistencytest outcome of BW, 95% CI of 8 loops was included 0,

which reflected that no significant inconsistency was found.However, another 2 loops (ACE-Acupuncture-Combinedtherapies; ACE-Combined theories-EA) were found statisti-cal inconsistency between direct and indirect comparisons.

3.6.2. BMI. For the inconsistency test outcome of body massindex, 95% CI of all loops (acupuncture -combined theories-EA; acupuncture-EA-placebo; AR+LM -EA- LM-placebo;ACE-acupuncture-EA; AAS-EA-LM; AAS-AR+LM-LM-placebo; AAS-EA-placebo) were included 0, which reflectedthat no significant inconsistency was found.

3.7. Safety. Ten RCTs [26–28, 31, 32, 35, 36, 38, 39, 45] report-ed adverse events, while nomajor complicationswere noticedin all included studies. Three included studies [35, 36, 39]reported that no adverse effects were noted in both exper-imental group and placebo group. In one included RCT,there were two patients reporting mild ecchymosis and oneabdominal discomfort case reported as adverse events afterelectroacupuncture treatment; no case was reported in thelifestyle modification group [27]. In another study, there wereseven subjects in group auricular acupoint stimulation andtwo subjects in group placebo had mild tenderness [32].

4. Discussion

The aim of this study was to identify the efficacy and safety ofacupoint stimulation therapy for obesity. In this NMA, theassociation of each acupuncture and related therapies withrelative weight loss was compared by the combination ofdirect and indirect evidence from 34 RCTs in 2283 obese pa-tients.

This study has three key findings. First, ranking graphsof the primary outcome suggested that the combination ofacupuncture and related therapies was the most effectivein losing weight and improving BMI. Second, comparedwith placebo or sham acupuncture, combination of acu-puncture-related therapies, manual acupuncture, acupoint

Evidence-Based Complementary and Alternative Medicine 15

Table5:Re

sults

ofnetworkmeta-analyses.

Body

weight

AAS

-1.11

(-4.01,1.71)

ACE

0.72

(-0.93,2.37

)1.8

2(-1.0

8,4.84)

AR+

LM-1.45(

-4.11,1.28)

-0.36(-1.8

2,1.3

1)-2.16

(-4.94,0.61)

Acup

unct

ure

-2.40(-5.16,0.35)

-1.28(-2.96,0.39

)-3

.09

(-5.

97,-

0.33

)-0.92(-2.34,0.30)

Com

bine

dth

eori

es-0.07(

-1.85,1.74)

1.05(-1.3

5,3.48)

-0.77(-2.61,1.03)

1.38(-0.77,3.57)

2.33

(0.17

,4.5

6)EA

1.80

(0.2

1,3.

41)

2.90

(0.16

,5.7

2)1.0

9(-0.27,2.39

)3.

26(0

.65,

5.88

)4.

18(1

.62,

6.83

)1.8

5(0

.37,

3.37

)LM

0.06

(-5.43,5.46)

1.11(-3.79,6.23)

-0.67(-6.27,4.70)

1.47(-3.37,6.35)

2.39

(-2.25,7.16

)0.11(-5.02,5.13

)-1.76

(-7.18,3.51)

Phar

mac

othera

py1.2

6(0

.46,

2.06

)2.37

(-0.43,5.18

)0.54

(-0.93,2.03)

2.72

(0.0

6,5.

29)

3.65

(0.9

6,6.

34)

1.33(

-0.36,2.96)

-0.55(

-2.02,0.90)

1.20(-4.13,6.63)

Plac

ebo

-3.47(

-8.46,1.3

5)-2.31

(-7.6

9,2.72)

-4.18

(-9.2

2,0.67)

-1.99(-7.32,2.93)

-1.04(-6.34,3.96)

-3.40(-8.10,1.06)

-5.2

4(-

10.15

,-0.

55)

-3.50(-10.48,3.39)

-4.72(-9.7

7,0.07)

WA

BMI

AAS

-0.08(-1.5

4,1.4

2)AC

E0.96

(-0.08,2.00)

1.03(-0.58,2.66)

AR+

LM-0.64(-1.4

8,0.35)-0.54(-1.8

8,0.84)

-1.5

9(-

2.71

,-0.

34)

Acup

unct

ure

-0.81(-1.77,0.12)

-0.71(-2.20,0.70)

-1.7

6(-

2.95

,-0.

62)

-0.16

(-1.0

1,0.43)

Com

bine

dth

eori

es0.04

(-0.68,0.78)

0.12

(-1.2

0,1.4

5)-0.92(-1.8

8,0.08)

0.67

(-0.11,

1.34)

0.84

(0.19

,1.5

8)EA

1.31(

0.36

,2.3

0)1.4

0(-0.18,2.96)

0.34

(-0.36,1.15

)1.9

4(0

.83,

3.00

)2.

12(1

.07,

3.23

)1.2

8(0

.43,

2.11

)LM

-0.31

(-2.14,1.55)

-0.21(-2.34,1.8

7)-1.26(-3.21,0.79)

0.33

(-1.4

6,2.01)

0.51

(-1.0

6,2.09)

-0.35(

-2.10

,1.39

)-1.62(-3.54,0.31

)Ph

arm

acot

hera

py0.

63(0

.25,

1.11)

0.72

(-0.71,2.15

)-0.32

(-1.2

8,0.69)

1.28

(0.4

3,2.

05)

1.44

(0.6

4,2.

38)

0.60

(0.0

3,1.2

2)-0.66(-1.5

8,0.26)

0.95

(-0.85,2.78)

Plac

ebo

BMI:bo

dymassind

ex;LM:lifesty

lemod

ificatio

n;AAS:auric

ularacup

ointstimulation;EA

:electroacup

uncture;AC

E:acup

ointcatgutem

bedd

ing;WA:w

arminga

cupu

ncture;A

R:acup

uncturea

ndrelatedtherapies;

combinedtherapies:combinatio

nof

acup

unctureandrelatedtherapies.

16 Evidence-Based Complementary and Alternative Medicine

0.2

.4.6

.81

0.2

.4.6

.81

0.2

.4.6

.81

0.2

.4.6

.81

0.2

.4.6

.81

0.2

.4.6

.81

0.2

.4.6

.81

0.2

.4.6

.81

0.2

.4.6

.81

0.2

.4.6

.81

1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10

1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10

1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10

AAS(48.3) ACE(62.1) AR+LM(31.2) Acupuncture(70.5)

Combined theories(88.7) EA(46.3) LM(6.4) PHA(41.9)

PLA(16.8) WA(87.8)

Cum

ulat

ive P

roba

bilit

ies

RankGraphs by Treatment

(a) Body weight

0.2

.4.6

.81

0.2

.4.6

.81

0.2

.4.6

.81

0.2

.4.6

.81

0.2

.4.6

.81

0.2

.4.6

.81

0.2

.4.6

.81

0.2

.4.6

.81

0.2

.4.6

.81

1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

AAS(55.7) ACE(58.6) AR+LM(16.9)

Acupuncture(83.3) Combined theories(90.2) EA(52.1)

LM(3.4) PHA(64.7) PLA(25.1)

Cum

ulat

ive P

roba

bilit

ies

RankGraphs by Treatment

(b) Body mass index

Figure 3: Surface under the cumulative ranking curves. LM: lifestyle modification; AAS: auricular acupoint stimulation; EA: electroacupunc-ture; ACE: acupoint catgut embedding; WA:warming acupuncture;AR: acupuncture and related therapies; combined therapies: combinationof acupuncture and related therapies; PLA: placebo; PHA: pharmacotherapy.

Evidence-Based Complementary and Alternative Medicine 17

catgut embedding, auricular acupuncture therapy, and elec-troacupuncture are all associated with higher odds of achiev-ing weight loss. Third, combination of acupuncture and re-lated therapies, manual acupuncture, pharmacotherapy, acu-point catgut embedding, auricular acupoint stimulation, andelectroacupuncture were superior to lifestyle intervention.

Lifestyle modification, like diet intervention and physicalactivity, is recommended as safe and effective way to loseweight [60]. Results of direct and indirect evidence suggestacupuncture and related theories had significant benefi-cial effects in dealing with obesity compared with lifestylemodification. Both experimental and clinical data prove theefficacy of acupuncture for obesity [61]. Experimental datasuggests that acupuncture exerts beneficial effects on weightloss [62, 63]. The majority of clinical evidence suggests thatacupuncture and related therapies reduced more weight thansham control group [26, 28, 31, 32], which are consistent withour results. Previous animal studies have observed that theexpression of obesity-related peptides was upregulated in thehypothalamus after acupuncture treatment, which inducedless food intake and weight loss [62, 64, 65]. Similarly, sig-nificant decreases in plasma leptin level were observed afterEA treatment in obese patients [46]. With regard to insulinlevel, several experimental studies reported that EA canimprove insulin sensitivity [66, 67]. However, results fromclinical trials regarding insulin levels are controversial.Cabioglu MT reported that EA increased insulin level com-pared with control group [56], but Gucel F indicated thatacupuncture decreased insulin level [46]. As to effects onlipid metabolism, acupuncture was reported to be effectivein decreasing total cholesterol (TC), triglycerides (TG) andLDL-C concentrations [68, 69] of obese rat. Significantdecreases in TC [55], TG [35], and LDL-C [55] were observedwhereas no changes in HDL-C [55] levels were observed inclinical trials. Furthermore, experimental studies suggest thatthere was significant decrease in serum TNF𝛼 after EA [70].Except for the noted mechanisms, EA can also induce whiteadipose tissue (WAT) browning via increasing uncouplingprotein-1 (UCP1) gene expression [71].

This NMA has several attractive advantages. We focusedon simple obesity patients without complication, which de-creased the heterogeneity and improve the quality of thisstudy. In addition, we compared acupuncture and acupunc-ture-related therapieswith the first-line treatment for obesity-lifestyle modification with a Bayesian framework. The ranktest of effectiveness provides data to favour acupunctureand acupuncture-related therapies. Lastly, we conducted acomprehensive search and included all eligible studies. Wecompared five different acupuncture treatments (manual acu-puncture; electro acupuncture; auricular acupoint stimula-tion; acupoint catgut embedding; moxibustion with warmingneedle) in the clinical effectiveness in treating patients withobesity.

However, this study has several limitations. First, wefailed to evaluate the safety of each acupoint stimulationtherapy due to the limited data in primary studies. Futuretrials should report adverse events clearly to improve thequality of study design. Second, unaddressed concerns stillexist regarding the long-term effects of using acupuncture

and acupuncture-related therapies on weight management ina clinical setting. The duration of acupuncture sessions andfollow-up duration of most included trials ranging fromfour weeks to twelve weeks. Further clinical evaluation ofacupuncture for obesity with longer follow-up appears war-ranted. Third, blinding of patients and researches was notapplied among included studies and the included trials weremainly conducted in China, which may lead to publicationbias [72]. Fourth, included study in our NMA lack of researchcompares the effectiveness between acupuncture, pharma-cotherapy, and different types of combination of acupuncture.Further confirmatory comparative effectiveness trials shouldcompare different types of combination of acupuncture. Ex-cept one study compared acupuncture and pharmacotherapy[29], additional research is needed to further explore. Finally,we use R-value to estimate the changes in standard deviations(SD), which might enlarge the SD compared with the origi-nals values.

Overall, our results indicate that combination of acu-puncture and related therapies ranks as the optimal methodfor reducing both weight and BMI. Further studies will clarifywhich combination of acupuncture and related therapies isbetter.

Data Availability

All data used to support the findings of this study are includedwithin the supplementary information files.

Conflicts of Interest

All authors declare that they have no potential conflicts ofinterest.

Authors’ Contributions

Yanji Zhang, Jia Li, and Guoyan Mo contributed equally tothis work. Wei Huang, Zhongyu Zhou, and Yanji Zhang con-tributed to study design. Xianglin Chen, Hui Liu, and TengCai contributed to study selection. Xiangmin Tian, Teng Cai,Xian Zhang, and Xianglin Chen contributed to data collec-tion and quality assessment. Figures 1–3 were prepared byJia Li and Jing Liu. Tables 1–5 were prepared by Guoyan Mo.Appendices 1–4 were prepared by Jia Li. Huisheng Yang andTeng Cai were responsible for technical and language sup-port. All authors have read and approved the final manu-script.

Acknowledgments

This research was supported by the National Nature ScienceFoundation of China (nos. 81674081 and 81804165), 2015Special Project in the TCM State Industry Administrationof Traditional Chinese Medicine of the People’s Republic ofChina (no. 201507003), Young Elite Scientist Sponsors HipProgram by CAST (no. 2017QNRC001), Hubei University ofTraditional ChineseMedicineAcupuncture andMoxibustion

18 Evidence-Based Complementary and Alternative Medicine

Research Team Project (no. 2017ZXZ004), and Science andTechnology Program of Hubei, China (no. 2016CFB221).

Supplementary Materials

Appendix 1: the PRISMA-NMA checklist treatment groupsfor included studies in a network meta-analysis. Appendix2: search strategies for RCTs on acupuncture for obesity.Appendix 3: summaries of mean, standard difference, andsample size between treatment groups for included studiesin a network meta-analysis. Appendix 4: inconsistency test.(Supplementary Materials)

References

[1] World Health Organization, “Fact Sheet Obesity and Over-weight 2013,” [WWW document], http://www.who.int/media-centre/factsheets/fs311/en/#, (accessed August 2014).

[2] W. T. Garvey, J. I. Mechanick, E. M. Brett et al., “American asso-ciation of clinical endocrinologists and American college ofendocrinology comprehensive clinical practice guidelines formedical care of patients with obesity,” Endocrine Practice, vol.22, pp. 1–203, 2016.

[3] C. L. Ogden, M. D. Carroll, B. K. Kit, and K. M. Flegal, “Pre-valence of childhood and adult obesity in the United States,2011-2012,”e Journal of the AmericanMedical Association, vol.311, no. 8, pp. 806–814, 2014.

[4] W. Xu, H. Zhang, S. Paillard-Borg, H. Zhu, X. Qi, and D.Rizzuto, “Prevalence of overweight and obesity among Chineseadults: Role of adiposity indicators and age,” Obesity Facts, vol.9, no. 1, pp. 17–28, 2016.

[5] J. Cawley and C. Meyerhoefer, “The medical care costs of obe-sity: an instrumental variables approach,” Journal of Health Eco-nomics, vol. 31, no. 1, pp. 219–230, 2012.

[6] R. Dalle Grave, S. Calugi, andM. El Ghoch, “Lifestyle modifica-tion in the management of obesity: Achievements and chal-lenges,” Eating andWeight Disorders, vol. 18, no. 4, pp. 339–349,2013.

[7] R. Khera, M. H. Murad, A. K. Chandar et al., “Association ofpharmacological treatments for obesity withweight loss and ad-verse events a systematic review and meta-analysis,” Journal ofthe American Medical Association, vol. 315, no. 22, pp. 2424–2434, 2016.

[8] P. R. Schauer, S. R. Kashyap, K. Wolski et al., “Bariatric sur-gery versus intensive medical therapy in obese patients withdiabetes,” e New England Journal of Medicine, vol. 366, no.17, pp. 1567–1576, 2012.

[9] S. Ikramuddin, J. Korner, W.-J. Lee et al., “Roux-en-Y gastricbypass vs intensive medical management for the control oftype 2 diabetes, hypertension, and hyperlipidemia: the diabetessurgery study randomized clinical trial,” e Journal of theAmerican Medical Association, vol. 309, no. 21, pp. 2240–2249,2013.

[10] L. O. Reis, W. J. Favaro, G. C. Barreiro et al., “Erectile dysfunc-tion and hormonal imbalance in morbidly obese male is re-versed after gastric bypass surgery: a prospective randomizedcontrolled trial,” International Journal of Andrology, vol. 33, no.5, pp. 736–744, 2010.

[11] V. L. Gloy, M. Briel, D. L. Bhatt et al., “Bariatric surgery versusnon-surgical treatment for obesity: a systematic review and

meta-analysis of randomised controlled trials,” British MedicalJournal, vol. 347, no. 5, 2013.

[12] S. Fang, M. Wang, Y. Zheng, S. Zhou, and G. Ji, “Acupunc-ture and lifestyle modification treatment for obesity: a meta-analysis,” American Journal of Chinese Medicine, vol. 45, no. 02,pp. 1–16, 2017.

[13] T.-L. Yeh, H.-H. Chen, T.-P. Pai et al., “The effect of auricularacupoint stimulation in overweight and obese adults: a system-atic review and meta-analysis of randomized controlled trials,”Evidence-Based Complementary and Alternative Medicine, vol.2017, Article ID 3080547, 16 pages, 2017.

[14] T. Guo, Y. Ren, J. Kou, J. Shi, S. Tianxiao, and F. Liang, “Acu-point catgut embedding for obesity: systematic review andmeta-analysis,” Evidence-Based Complementary and AlternativeMedicine, vol. 2015, Article ID 401914, 20 pages, 2015.

[15] A. Chaimani, J. P. T. Higgins, D.Mavridis, P. Spyridonos, andG.Salanti, “Graphical tools for network meta-analysis in STATA,”PLoS ONE, vol. 8, no. 10, 2013.

[16] G. Salanti, C. Del Giovane, A. Chaimani, D. M. Caldwell, J. P.Higgins, and Y. Tu, “Evaluating the quality of evidence from anetwork meta-analysis,” PLoS ONE, vol. 9, no. 7, 2014.

[17] B.Hutton,G. Salanti, D.M.Caldwell et al., “ThePRISMAexten-sion statement for reporting of systematic reviews incorporat-ing network meta-analyses of health care interventions: Check-list and explanations,” Annals of Internal Medicine, vol. 162, no.11, pp. 777–784, 2015.

[18] The Cochrane Collaboration, “Cochrane handbook for sys-tematic reviews of interventions,” 2011, http://www.cochrane.org/training/cochrane-handbook.

[19] K. R. Abrams, C. L. Gillies, and P. C. Lambert, “Meta-analysis ofheterogeneously reported trials assessing change frombaseline,”Statistics in Medicine, vol. 24, no. 24, pp. 3823–3844, 2005.

[20] J. P. T. Higgins, D. G. Altman, P. C. Gøtzsche et al., “The Co-chrane Collaboration’s tool for assessing risk of bias in rando-mised trials,” British Medical Journal, vol. 343, no. 24, 2011.

[21] J. P. T. Higgins, S. G. Thompson, J. J. Deeks, and D. G. Altman,“Measuring inconsistency in meta-analyses,” British MedicalJournal, vol. 327, no. 7414, pp. 557–560, 2003.

[22] A. E. Ades, M. Sculpher, A. Sutton et al., “Bayesian methods forevidence synthesis in cost-effectiveness analysis,” Pharma-coEconomics, vol. 24, no. 1, pp. 1–19, 2006.

[23] G. Lu and A. E. Ades, “Combination of direct and indirect evi-dence in mixed treatment comparisons,” Statistics in Medicine,vol. 23, no. 20, pp. 3105–3124, 2004.

[24] G. van Valkenhoef, G. Lu, B. de Brock, H. Hillege, A. E. Ades,andN. J.Welton, “Automatingnetworkmeta-analysis,”ResearchSynthesis Methods, vol. 3, no. 4, pp. 285–299, 2012.

[25] G. Salanti, A. E. Ades, and J. P. A. Ioannidis, “Graphicalmethodsand numerical summaries for presenting results frommultiple-treatment meta-analysis: an overview and tutorial,” Journal ofClinical Epidemiology, vol. 64, no. 2, pp. 163–171, 2011.

[26] D. B. Allison, K. Kreibich, and S. Heshka, “A randomised place-bo-controlled clinical trial of an acupressure device for weightloss,” International Journal of Obesity and Related MetabolicDisorders, vol. 19, no. 9, pp. 653–658, 1995.

[27] C.-H. Hsu, K.-C. Hwang, C.-L. Chao, J.-G. Lin, S.-T. Kao, andP. Chou, “Effects of electroacupuncture in reducing weight andwaist circumference in obese women: a randomized crossovertrial,” International Journal of Obesity, vol. 29, no. 11, pp. 1379–1384, 2005.

Evidence-Based Complementary and Alternative Medicine 19

[28] D. Richards and J. Marley, “Stimulation of auricular acupunc-ture points in weight loss,” Australian Family Physician, vol. 2,no. 27, pp. S73–S77, 1998.

[29] L. He, X.-L. Gao, H.-X. Deng, and Y.-X. Zhao, “Effects of acu-puncture on body mass index and waist-hip ratio in the patientof simple obesity,” Chinese Acupuncture &Moxibustion, vol. 28,no. 2, pp. 95–97, 2008 (Chinese).

[30] L. Li and Z.-Y. Wang, “Clinical therapeutic effects of body acu-puncture and ear acupuncture on juvenile simple obesity andeffects on metabolism of blood lipids,” Chinese Acupuncture &Moxibustion, vol. 26, no. 3, pp. 173–176, 2006.

[31] J. Tong, J. X. Chen, Z. Q. Zhang et al., “Clinical observation onsimple obesity treated by acupuncture,”Chinese Acupuncture &Moxibustion, vol. 31, no. 8, pp. 679–701, 2011.

[32] C.-H.Hsu, C.-J.Wang, K.-C. Hwang, T.-Y. Lee, P. Chou, andH.-H.Chang, “The effect of auricular acupuncture in obesewomen:a randomized controlled trial,” Journal of Women’s Health, vol.18, no. 6, pp. 813–818, 2009.

[33] C. H. Hsieh, “The effects of auricular acupressure on weightloss and serum lipid levels in overweight adolescents,”AmericanJournal of Chinese Medicine, vol. 38, no. 4, pp. 675–682, 2010.

[34] C. H. Hsieh, T.-J. Su, Y.-W. Fang, and P.-H. Chou, “Effects ofauricular acupressure on weight reduction and abdominal obe-sity in asian young adults: a randomized controlled trial,”American Journal of Chinese Medicine, vol. 39, no. 3, pp. 433–440, 2011.

[35] H. Abdi, P. Abbasi-Parizad, B. Zhao et al., “Effects of auricularacupuncture on anthropometric, lipid profile, inflammatory,and immunologic markers: a randomized controlled trialstudy,”e Journal of Alternative and Complementary Medicine,vol. 18, no. 7, pp. 668–677, 2012.

[36] M. Darbandi, S. Darbandi, M. G. Mobarhan et al., “Effects ofauricular acupressure combined with low-Calorie diet on theleptin hormone in obese and overweight iranian individuals,”Acupuncture in Medicine, vol. 30, no. 3, pp. 208–213, 2012.

[37] W. He, Z. Zhou, J. Li, L. Wang, B. Zhu, and G. Litscher, “Auricu-lar acupressure plus exercise for treating primary obesewomen:a randomized controlled clinical trial,” Medical Acupuncture,vol. 24, no. 4, pp. 227–232, 2012.

[38] C. Y. Lien, L. L. Liao, P. Chou, and C. H. Hsu, “Effects of auric-ular stimulation on obese women: a randomized, controlledclinical trial,” European Journal of Integrative Medicine, vol. 4,no. 1, pp. e45–e53, 2012.

[39] M. Darbandi, S. Darbandi, A. A. Owji et al., “Auricular or bodyacupuncture: Which one is more effective in reducing abdo-minal fat mass in Iranian men with obesity: A randomizedclinical trial,” Journal of Diabetes and Metabolic Disorders, vol.13, no. 1, 2014.

[40] M.-L. Yeh, N.-F. Chu,M.-Y. F. Hsu, C.-C.Hsu, andY.-C. Chung,“Acupoint stimulation on weight reduction for obesity: a ran-domized sham-controlled study,” Western Journal of NursingResearch, vol. 37, no. 12, pp. 1517–1530, 2015.

[41] F. Chen, S. Wu, and Y. Zhang, “Effect of acupoint catgut em-bedding on TNF-alpha and insulin resistance in simple obesitypatients,” Acupuncture Research, vol. 32, no. 1, pp. 49–52, 2007.

[42] L.-C. Huang and W.-Y. Pan, “Comparation of effect and cost-benefit analysis between acupoint catgut-embedding and elec-troacupuncture on simple obesity,” Chinese Acupuncture &Moxibustion, vol. 31, no. 10, pp. 883–886, 2011.

[43] C.-L. Tang, D.-C. Dai, G.-F. Zhao, W.-F. Zhu, and L.-F. Mei,“Clinical observation on electroacupuncture combined with

catgut implantation at acupoints for treatment of simple obesityof heart and spleen deficiency type,” Chinese Acupuncture &Moxibustion, vol. 29, no. 9, pp. 703–707, 2009.

[44] Y. Shi, L.-S. Zhang, C. Zhao, and C.-Q. He, “Comparison oftherapeutic effects of acupuncture-cuppingplus acupoint catgutembedding and electroacupuncture on simple obesity of stom-ach and intestine excess-heat type,” Chinese Acupuncture &Moxibustion, vol. 26, no. 8, pp. 547–550, 2006.

[45] C.-H. Hsu, K.-C. Hwang, C.-L. Chao, H.-H. Chang, and P.Chou, “Electroacupuncture in obese women: A randomized,controlled pilot study,” Journal of Women’s Health, vol. 14, no.5, pp. 434–440, 2005.

[46] F. Gucel, B. Bahar, C. Demirtas, S. Mit, and C. Cevik, “Influenceof acupuncture on leptin, ghrelin, insulin and cholecystokininin obese women: a randomised, sham-controlled preliminarytrial,” Acupuncture in Medicine, vol. 30, no. 3, pp. 203–207, 2012.

[47] L. Deng, Z. Lun, X. Ma, and J. Zhou, “Clinical observation onregulating the three energizer by acupoint catgut embeddingcombined with abdominal acupuncture in treating abdomi-nal obesity: a randomized controlled trial,” World Journal ofAcupuncture - Moxibustion, vol. 24, no. 4, pp. 29–34, 2014.

[48] N. E. Hassan, S. A. El-Masry, S. M. Elshebini et al., “Compar-ison of three protocols: Dietary therapy and physical activity,acupuncture, or laser acupuncture in management of obesefemales,” Macedonian Journal of Medical Sciences, vol. 7, no. 2,pp. 191–197, 2014.

[49] J. He, X. Zhang, Y. Qu et al., “Effect of combined manual acu-puncture andmassage on body weight and body mass index re-duction in obese and overweight women: a randomized, short-term clinical trial,” Journal of Acupuncture andMeridian Studies,vol. 8, no. 2, pp. 61–65, 2015.

[50] Y. L. Wang, X. Cao, Z. C. Liu, and B. Xu, “Observation on thetherapeutic effect of electroacupuncture on simple obesity ofgastrointestinal heat pattern/syndrome,”World Journal of Acu-puncture - Moxibustion, vol. 23, no. 2, pp. 1–5, 2013.

[51] S. Yeo, K. S. Kim, and S. Lim, “Randomised clinical trial of fiveear acupuncture points for the treatment of overweight people,”Acupuncture in Medicine, vol. 32, no. 2, pp. 132–138, 2014.

[52] T.W. Bu, X. L. Tian, S. J. Wang et al., “Comparison and analysisof therapeutic effects of different therapies on simple obesity,”Chinese Acupuncture &Moxibustion, vol. 27, no. 5, pp. 337–340,2007.

[53] Y. Shi, L.-S. Zhang, C. Zhao, and X.-Y. Zuo, “Controlled studyof needle warming therapy and electroacupuncture on simpleobesity of spleen deficiency type,” Chinese Acupuncture &Moxibustion, vol. 25, no. 7, pp. 465–467, 2005.

[54] J.-J. Yang, H.-J. Xing, H.-L. Xiao, Q. Li, M. Li, and S.-J. Wang,“Effects of acupuncture combined with diet adjustment andaerobic exercise on weight and waist-hip ratio in simple obesitypatients,”Chinese Acupuncture &Moxibustion, vol. 30, no. 7, pp.555–558, 2010.

[55] M. T. Cabıoglu and N. Ergene, “Electroacupuncture therapy forweight loss reduces serum total cholesterol, triglycerides, andLDL cholesterol levels in obese women,” American Journal ofChinese Medicine, vol. 33, no. 4, pp. 525–533, 2005.

[56] M. T. Cabioglu andN. Ergene, “Changes in levels of serum insu-lin, C-peptide and glucose after electroacupuncture and diettherapy in obese women,” American Journal of Chinese Medi-cine, vol. 34, no. 3, pp. 367–376, 2006.

[57] M. T. Cabioglu, N. Gundogan, and N. Ergene, “The efficacyof electroacupuncture therapy for weight loss changes plasma

20 Evidence-Based Complementary and Alternative Medicine

lipoprotein A, Apolipoprotein A and Apolipoprotein B levels inobese women,” American Journal of Chinese Medicine, vol. 36,no. 6, pp. 1029–1039, 2008.

[58] S. Darbandi, M. Darbandi, and P. Mokarram, “Effects of bodyelectroacupuncture on plasma leptin concentrations in obeseand overweight people in Iran: a randomized controlled trial,”Alternative erapies in Health and Medicine, vol. 19, no. 2, pp.24–31, 2013.

[59] S. Fogarty, L. Stojanovska,D.Harris, C. Zaslawski,M. L.Mathai,and A. J. McAinch, “A randomised cross-over pilot study inves-tigating the use of acupuncture to promote weight loss andmental health in overweight and obese individuals participatingin a weight loss program,” Eating and Weight Disorders, vol. 20,no. 3, pp. 379–387, 2015.

[60] W. T. Garvey, J. I. Mechanick, E. M. Brett et al., “American asso-ciation of clinical endocrinologists and American college ofendocrinology comprehensive clinical practice guidelines formedical care of patients with obesity: Executive summary,”Endocrine Practice, vol. 22, no. 7, pp. 842–884, 2016.

[61] M. Belivani, C. Dimitroula, N. Katsiki, M. Apostolopoulou, M.Cummings, andA. I. Hatzitolios, “Acupuncture in the treatmentof obesity: a narrative review of the literature,” Acupuncture inMedicine, vol. 31, no. 1, pp. 88–97, 2013.

[62] D.-R. Tian, X.-D. Li, F. Wang et al., “Up-regulation of the ex-pression of cocaine and amphetamine-regulated transcriptpeptide by electroacupuncture in the arcuate nucleus of diet-induced obese rats,” Neuroscience Letters, vol. 383, no. 1-2, pp.17–21, 2005.

[63] N. Tian, F. Wang, D.-R. Tian et al., “Electroacupuncture sup-presses expression of gastric ghrelin and hypothalamic NPY inchronic food restricted rats,” Peptides, vol. 27, no. 9, pp. 2313–2320, 2006.

[64] F. Wang, D. R. Tian, P. Tso, and J. S. Han, “Arcuate nucleus ofhypothalamus is involved in mediating the satiety effect of elec-troacupuncture in obese rats,” Peptides, vol. 32, no. 12, pp. 2394–2399, 2011.

[65] Z. Liu, F. Sun, J. Su et al., “Study on action of acupuncture onventromedial nucleus of hypothalamus in obese rats,” Journal ofTraditional Chinese Medicine, vol. 21, no. 3, pp. 220–224, 2001.

[66] J.-G. Lin, W.-C. Chen, C.-L. Hsieh et al., “Multiple sources ofendogenous opioid peptide involved in the hypoglycemic re-sponse to 15 Hz electroacupuncture at the Zhongwan acupointin rats,” Neuroscience Letters, vol. 366, no. 1, pp. 39–42, 2004.

[67] Y. Higashimura, R. Shimoju, H. Maruyama, and M. Kurosawa,“Electro-acupuncture improves responsiveness to insulin viaexcitation of somatic afferent fibers in diabetic rats,”AutonomicNeuroscience: Basic and Clinical, vol. 150, no. 1-2, pp. 100–103,2009.

[68] S. Wang, Q. Li, Y. She et al., “Effect of electroacupuncture onmetabolism of lipids in rats of obesity induced by sodiumglutamate,” Chinese Acupuncture & Moxibustion, vol. 25, no. 4,pp. 269–271, 2005.

[69] S. J. Wang, H. Z. Xu, and H. L. Xiao, “Effect of high-frequen-cy electroacupuncture on lipid metabolism in obesity rats,”Acupuncture Research, vol. 33, no. 3, pp. 154–158, 2008.

[70] H. Yang, Y. Li, L. Cheng, and J.-S. He, “Effect of electroacupunc-ture and diet adjusting on insulin resistance in rats withnutrition obesity,” Journal of Chinese Integrative Medicine, vol.5, no. 5, pp. 546–549, 2007.

[71] W. Shen, Y. Wang, S.-F. Lu et al., “Acupuncture promotes whiteadipose tissue browning by inducing UCP1 expression on DIO

mice,” BMC Complementary and Alternative Medicine, vol. 14,no. 1, pp. 54–59, 2014.

[72] M. J. Page, J. P. Higgins, G. Clayton et al., “Empirical evidenceof study design biases in randomized trials: systematic reviewof meta-epidemiological studies,” PLoS ONE, vol. 11, no. 7, pp.5–9, 2016.

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